consulate general of the republic of indonesia Melbourne Australia
recent colour photo 3.5 x 4.5 cm do not staple
72 Queens Road Melbourne Victoria 3004 T 03 9525 2755 | F 03 9525 1588 www.kjri-melbourne.org
V 03
journalistic visa application Fill in with ink and use block letters. attach 3 (three) passport size photographs. Personal Details Full name
Place/Date of birth
DD
MM
YYYY
Nationality
Passport number
Present occupation Residential address Company/media Address of company Type of media
Newspaper
Radio
Television
Other
Previous publications (books/papers/etc) Proposed subjects of study/observation/ coverage in Indonesia Duration of stay
Day(s)
Month(s)
Year(s)
Port of entry Present status (if any) in other organisation/ club/sports/political/etc curriculum vitae Education and training background
Professional and career background
Signature
Page 1 of 6
Melbourne
DD
MM
YYYY
DEPARTEMEN LUAR NEGERI REPUBLIK INDONESIA DEPARTMENT OF FOREIGN AFFAIRS OF THE REPUBLIC OF INDONESIA APPLICATION FOR FILM/VIDEO SHOOTING PERMIT (PERMOHONAN IZIN UNTUK SHOOTING FILM/video) Applicant’s full name
Nama lengkap pemohon
Place/Date of birth
Tempat/tanggal lahir
Nationality
DD
MM
YYYY
DD
MM
YYYY
DD
MM
YYYY
Kebangsaan
Passport number Nomor paspor
Date of issue
DD MM YYYY
Tanggal dikeluarkan
Place of issue
Tempat dikeluarkan
Date of expiry
Berlaku s/d
Residential address
Alamat pemohon
City
Kota
Telephone
Occupation
Telepon
State/Postcode
Kodepos
Mobile
Handphone
Jabatan
Name of company
Nama perusahaan
Address of company
Alamat perusahaan
City
Kota
Telephone
Telepon
State/Postcode
Kodepos
Facsimile
Facsimile
Purpose of production Tujuan produksi
Previous film/video shooting experience in Indonesia
Pengalaman shooting film/ video di Indonesia sebelumnya
curriculum vitae Education and training background
Latar belakang pendidikan dan pelatihan
Professional and career background Latar belakang profesional dan karir
Signature
Page 2 of 6
Melbourne
crew (kerabat kerja) 1. Full name
Nama lengkap
Occupation Jabatan
Passport number Nomor paspor
Date of issue
DD MM YYYY
Place of issue
Tempat dikeluarkan
Date of expiry
Tanggal dikeluarkan
DD
MM
YYYY
DD
MM
YYYY
DD
MM
YYYY
DD
MM
YYYY
DD
MM
YYYY
DD
MM
YYYY
DD
MM
YYYY
DD
MM
YYYY
Berlaku s/d
2. Full name
Nama lengkap
Occupation Jabatan
Passport number Nomor paspor
Date of issue
DD MM YYYY
Place of issue
Tempat dikeluarkan
Date of expiry
Tanggal dikeluarkan
Berlaku s/d
3. Full name
Nama lengkap
Occupation Jabatan
Passport number
Date of issue
Nomor paspor
DD MM YYYY
Place of issue
Tempat dikeluarkan
Date of expiry
Tanggal dikeluarkan
Berlaku s/d
4. Full name
Nama lengkap
Occupation Jabatan
Passport number
Date of issue
Nomor paspor
DD MM YYYY
Place of issue
Tempat dikeluarkan
Date of expiry
Tanggal dikeluarkan
Berlaku s/d
5. Full name
Nama lengkap
Occupation Jabatan
Passport number
Date of issue
Nomor paspor
DD MM YYYY
Place of issue
Tempat dikeluarkan
Date of expiry
Tanggal dikeluarkan
Berlaku s/d
6. Full name
Nama lengkap
Occupation Jabatan
Passport number
Date of issue
Nomor paspor
DD MM YYYY
Place of issue
Tempat dikeluarkan
Date of expiry
Tanggal dikeluarkan
Berlaku s/d
7. Full name
Nama lengkap
Occupation Jabatan
Passport number
Date of issue
Nomor paspor
DD MM YYYY
Place of issue
Tempat dikeluarkan
Date of expiry
Tanggal dikeluarkan
Berlaku s/d
8. Full name
Nama lengkap
Occupation Jabatan
Passport number Nomor paspor
Date of issue
DD MM YYYY
Place of issue
Tempat dikeluarkan
Date of expiry
Tanggal dikeluarkan
Berlaku s/d
Page 3 of 6
DEPARTEMEN LUAR NEGERI REPUBLIK INDONESIA DEPARTMENT OF FOREIGN AFFAIRS OF THE REPUBLIC OF INDONESIA Statement To complete our application for photography, film/video shooting permit, we hereby declare that: 1. We shall obey all the rules and regulations issued by the Government of the Republic of Indonesia, whether they are the ones issued by the Central Government or by the Local Government. 2. We are aware of the obligation to report, upon arrival, to the Department of Foreign Affairs cq the Directorate of Foreign Affairs Information for a general briefing on film/video shooting procedures in Indonesia. 3. We shall not make any shooting or recording of any object/location other than what are indicated in the shooting permit based on the script/synopsis forwarded by us. 4. We shall neither make any shooting/recording of prohibited objects and restricted locations nor of any other objects/locations which might create a harmful impression to the image of the government and the nation. 5. We shall be responsible and pay full compensation for the expense that might be occurring from filming/recording prohibited objects and restricted areas. 6. We agree to bear all the expenses of a Department’s official appointed to accompany the team during filming/recording, i.e. board and lodging, transportation cost, daily allowance and any other additional expenses that might occur during filming/recording. 7. We are to re-export all equipment after completion of our activities; 8. We are to submit one release copy of the film/video to the Department of Foreign Affairs cq Directorate of Foreign Affairs Information through the Indonesian Embassy, and we have no objection whatsoever to its being used by the Indonesian government for non-commercial purposes based on national interest in Indonesia as well as abroad.
Signature
Page 4 of 6
Melbourne
DD
MM
YYYY
details of visit to indonesia
No
Date Location DD
MM
Subject/Activity
YYYY
Page 5 of 6
details of equipment
Item no
Description of equipment
No Weight
Page 6 of 6
Value (US$)
Country of Origin
